Evaluation of the relationship between plasma viscosity and selected menopausal symptoms using the Menopause Rating Scale

OBJECTIVE

The aim of this study was to investigate whether whole blood viscosity and plasma viscosity are associated with the severity of postmenopausal symptoms using the Menopause Rating Scale (MRS).

METHODS

This study included 108 postmenopausal women admitted to menopause clinics. Participants were divided into two groups according to their MRS scores. Groups 1 (n = 52) and 2 (n = 56) were composed of healthy postmenopausal women with MRS scores of <14 and ≥14 points, respectively. The clinical findings and hemorheological parameters were compared between the two groups.

RESULTS

Comparing plasma viscosity levels between the two groups showed that group 1 had 1.25 ± 0.08 centipoise, whereas group 2 had 1.30 ± 0.10 centipoise ( P = 0.03). The difference in plasma viscosity between the two groups persisted after adjustment for age (1.24 ± 0.08 vs 1.31 ± 0.10; P < 0.001). Plasma viscosity was also significantly correlated with age ( r = 0.384, P < 0.001), menopausal duration ( r = 0.362, P < 0.001), and urogenital symptoms ( r = 410, P < 0.001).

CONCLUSIONS

Increased plasma viscosity levels were significantly associated with selected postmenopausal symptoms, independent of age.

Menopausal Symptoms among Postmenopausal Women of a Selected Municipality: A Cross-sectional Survey

Introduction: Postmenopausal women experience various menopause-specific somatic, psychological, and urogenital symptoms which tend to affect their overall well-being. However, there is a scant focus on menopausal health problems of postmenopausal women in Nepal. The aim of the study was to find out the prevalence of menopausal symptoms among postmenopausal women of a Municipality. Methods: A cross-sectional survey was conducted in selected wards of Tokha Municipality of Kathmandu district among postmenopausal women aged 45-60 years from September to October 2019. Ethical approval was taken from the Ethical Review Board, Nepal Health Research Council (reference number 694). Random sampling was used as the sampling technique. Face-to-face interview was used for data collection while a semi-structured interview schedule including the Nepali version of Menopause Rating Scale was used as a tool for measuring menopausal symptoms. EpiData version 3.1 was used for data entry while data analysis was performed using Statistical Packages for the Social Sciences version 20. Results: Amongst the postmenopausal women, all 203 (100%) had menopausal symptoms with majority reporting milder symptoms as found in 143 (70.4%). The mean Menopause Rating Scale (MRS) score was obtained as 13.21±5.1. The most prevalent moderate and mild symptoms were vaginal dryness 94 (46.3%), and depressive mood 71 (35%) respectively while physical and mental exhaustion 175 (86.2%) was the most common in all forms. Over half 102 (50.2%) of the respondents were unaware of menopausal symptoms and almost three-fifth 121 (59.6%) reported menopause related symptoms affected their daily work activities. Conclusions: The majority of postmenopausal women in this study had milder menopausal symptoms, which parallels findings from other national studies.

The Menopause Transition: Signs, Symptoms, and Management Options

CONTEXT

Menopause, the permanent cessation of menses, reflects oocyte depletion and loss of gonadal steroids. It is preceded by a transition state, the perimenopause, which is characterized by the gradual loss of oocytes, altered responsiveness to gonadal steroid feedback, wide hormonal fluctuations, and irregular menstrual patterns. The goal of this mini-review is to discuss the basic pathophysiology of the menopausal transition and the hormonal and nonhormonal management of clinicopathology attributed to it.

EVIDENCE ACQUISITION

A Medline search of epidemiologic, population-based studies, and studies of reproductive physiology was conducted. A total of 758 publications were screened.

EVIDENCE SYNTHESIS

The reproductive hormonal milieu of the menopausal transition precipitates bothersome vasomotor symptoms, mood disruption, temporary cognitive dysfunction, genitourinary symptoms, and other disease processes that reduce the quality of life of affected women. The endocrine tumult of the menopause transition also exposes racial and socioeconomic disparities in the onset, severity, and frequency of symptoms. Hormone therapy (HT) treatment can be effective for perimenopausal symptoms but its use has been stymied by concerns about health risks observed in postmenopausal HT users who are older than 60 and/or women who have been postmenopausal for greater than 10 years.

CONCLUSIONS

The menopause transition is a disruptive process that can last for over a decade and causes symptoms in a majority of women. It is important for clinicians to recognize early signs and symptoms of the transition and be prepared to offer treatment to mitigate these symptoms. Many safe and effective options, including HT, are available.

A comparison of three outcome measures of the impact of vasomotor symptoms on women's lives

Objective: Measures of the impact of vasomotor symptoms (VMS) have been used as outcomes in clinical trials but have not been compared. This study compares the Hot Flush Rating Scale (HFRS), the Hot Flash Related Daily Interference Scale (HFRDIS), and the shorter Hot Flash Interference (HFI) scale. Methods: Baseline data were taken from two studies including healthy women (menopause transition or postmenopause) and breast cancer patients experiencing VMS. Participants completed questionnaires on sociodemographics, the HFRS, the HFRDIS, the HFI, the Work and Social Adjustment Scale (WSAS), on depression (Generalized Anxiety Disorder 7), on anxiety (Patient Health Questionnaire 9), and on use of medical services. Results: A total of 169 women (129 with history of breast cancer and 40 without) aged 54.47 (standard deviation [SD] = 9.11) years took part. They had an average of 66 (SD = 40.94) VMS per week, with a mean HFRS problem-rating of 6.53 (SD = 1.99), HFRDIS score of 5.36 (SD = 2.22), and HFI score of 6.13 (SD = 2.30). The HFRS problem-rating, HFRDIS, and HFI were significantly associated (r = 0.61-0.85), had good internal reliability (α = 0.76-0.91), and had significant concurrent validity with mood, the WSAS, and use of medical services. VMS frequency was not associated with mood, the WSAS, or use of medical services. Conclusion: The HFRS problem-rating scale and the HFI are two brief, three-item measures that measure a similar concept of VMS interference/impact, with evidence of reliability and validity.

Longitudinal course of vasomotor symptoms in perimenopausal migraineurs

OBJECTIVE

To examine the longitudinal course of vasomotor symptoms (VMS) in women with a history of migraine in comparison to women without a history of migraine disease.

METHODS

The study sample consisted of 467 women with a self-reported prior migraine diagnosis and 2,466 women without prior migraine diagnosis who were assessed longitudinally during menopausal transition as part of the Study of Women's Health Across the Nation. Linear mixed regression models with backward elimination were used to evaluate longitudinal associations between VMS and migraine while adjusting for baseline and time-varying demographic, socioeconomic, psychological, and reproductive factors. Additional analyses were performed to further assess the specificity of the association between migraine and VMS that included evaluating the association between migraine and vaginal dryness and between back pain and VMS.

RESULTS

A history of migraine predicted an increased frequency of VMS but not vaginal dryness during menopausal transition. Significant interaction between history of migraine and menopausal status for the prediction of VMS was also identified. Burden of VMS was found to be higher during late-stage perimenopause in women with migraine. In contrast, the history of back pain did not predict the frequency of VMS.

INTERPRETATION

This is the first study to delineate that a history of migraine predicts an increased frequency of VMS in women during menopausal transition. Hypothalamic abnormalities and thermoregulatory dysfunction against a milieu of decreasing estradiol concentrations during menopausal transition may explain the increased frequency of VMS in migraineurs during menopausal transition. ANN NEUROL 2019;85:865-874.

Vasomotor symptoms and the risk of incident venous thrombosis in postmenopausal women

Essentials Vasomotor symptoms have been proposed as markers of changing cardiovascular risk. In this cohort study, we evaluated these symptoms as markers of venous thrombosis (VT) risk. We found no evidence that vasomotor symptom presence or severity were associated with VT risk. Among these postmenopausal women, vasomotor symptoms are not a useful marker of VT risk.

SUMMARY

Background Vasomotor symptoms may be markers of changes in cardiovascular risk, but it is unknown whether these symptoms are associated with the risk of venous thrombosis (VT). Objective To evaluate the association of vasomotor symptom presence and severity with incident VT risk among postmenopausal women, independent of potential explanatory variables. Methods This cohort study included participants of the Women's Health Initiative (WHI) Hormone Therapy Trials (n = 24 508) and Observational Study (n = 87 783), analyzed separately. At baseline, women reported whether hot flashes or night sweats were present and, if so, their severity. Using Cox proportional hazards models, we estimated the VT risk associated with vasomotor symptom presence and severity, adjusted for potential explanatory variables: age, body mass index, smoking status, race/ethnicity, and time-varying current hormone therapy use. Results At baseline, WHI Hormone Therapy Trial participants were aged 64 years and WHI Observational Study participants were aged 63 years, on average. In the WHI Hormone Therapy Trials over a median of 8.2 years of follow-up, 522 women experienced a VT event. In the WHI Observational Study, over 7.9 years of follow-up, 1103 women experienced a VT event. In adjusted analyses, we found no evidence of an association between vasomotor symptom presence (hazard ratio [HR]adj  0.91, 95% confidence interval [CI] 0.75-1.1 in the WHI Hormone Therapy Trials; HRadj  1.1, 95% CI 0.99-1.3 in the WHI Observational Study) or severity (HRadj for severe versus mild 0.99, 95% CI 0.53-1.9 in the WHI Hormone Therapy Trials; HRadj  1.3, 95% CI 0.89-2.0) in the WHI Observational Study) and the risk of incident VT. Conclusions Although vasomotor symptoms have been associated with the risk of other cardiovascular events in published studies, our findings do not suggest that vasomotor symptoms constitute a marker of VT risk.

MANAGEMENT OF ENDOCRINE DISEASE: Flushing: current concepts

OBJECTIVE

Flushing can be defined as a sensation of warmth accompanied by erythema that most commonly is seen on the face and which occurs in episodic attacks. Such a problem can be clinically problematic, since many conditions and drugs can be related to flushing, and while often there appears to be no underlying organic disease, it is important to exclude disorders since they may be life-threatening conditions.

DESIGN AND METHODS

We performed a search in MEDLINE using the terms 'flushing' in combination with 'carcinoid syndrome', 'pheochromocytoma', 'mastocytosis', 'menopausal hot flush' and 'treatment'. European and American guidelines relating to neuroendocrine tumours, mastocytosis and menopause were reviewed.

RESULTS

In this review, we discuss the main causes of flushing and propose an algorithm based on pathogenesis, which can be used to guide the clinical evaluation process. We also review recent significant developments in the assessment and treatment of the carcinoid syndrome and menopausal hot flushes, which should guide the clinical practice regarding this common but sometimes confusing condition.

CONCLUSIONS

When evaluating flushing, a precise systematic approach is needed to exclude potentially serious underlying causes, although despite this, the cause of the disorder is not always found. If symptoms are not progressive, the patient should be advised about its apparently benign nature in order to avoid unnecessary studies or initiating treatments of minimal benefit.

Longitudinal Study of Insomnia Symptoms Among Women During Perimenopause

OBJECTIVE

To describe the prevalence of insomnia symptoms among women during perimenopause and to examine differences in self-reported insomnia symptoms at different stages of perimenopause over 10 years.

DESIGN

Secondary analysis of self-reported sleep symptoms and clinical variables using 10 years of publicly available data from the Study of Women Across the Nation (SWAN).

SETTING

The data set of women's insomnia symptoms was obtained from publicly available data from the SWAN. The parent study settings included Detroit, Michigan; Northern New Jersey; Los Angeles, California; Boston, Massachusetts; Chicago, Illinois; and Pittsburgh, Pennsylvania.

PARTICIPANTS

Multiethnic midlife women with a mean age of 46 years (N = 3,302) categorized as pre- and perimenopausal at baseline.

METHODS

Dependent variables included self-reported insomnia symptoms: difficulty falling asleep (sleep latency), wake after sleep onset, early morning awakenings, and sleep quality. Descriptive analysis was completed for each 1-year study interval. Repeated measures logistic regression was used to identify whether insomnia symptoms changed over time by stage of perimenopause.

RESULTS

Insomnia symptoms were present in 31% to 42% of perimenopausal women at any 1-year study interval. Insomnia symptoms were more prevalent in the late stage of perimenopause than the early stage (p < .001). The odds of having any insomnia symptoms were 1.3 times greater for women in the late stage of perimenopause than in the early stage (95% confidence interval [1.2, 1.5], p < .001).

CONCLUSION

Insomnia symptoms are prevalent in women transitioning to menopause, and stage of perimenopause may heighten the risk to develop symptoms of insomnia disorder, which is associated with negative cardiometabolic outcomes.

Hot Flash Frequency and Blood Pressure: Data from the Study of Women's Health Across the Nation

BACKGROUND

Vasomotor symptoms (VMS) are highly prevalent among midlife women and have been associated with subclinical cardiovascular disease (CVD). However, the association between VMS frequency and risk factors such as hypertension (HTN) remains unclear.

MATERIALS AND METHODS

We examined VMS frequency and blood pressure (BP) among 2839 participants of the Study of Women's Health Across the Nation (SWAN), a multiethnic, prospective, study of women enrolled from seven U.S. sites between November 1995 and October 1997. Women were age 42-52, with no history of CVD, and not postmenopausal at baseline. VMS was defined by the number of days a woman reported VMS over the 2-week period before each annual visit. Frequent VMS was defined as ≥6 days of VMS; less frequent VMS was defined 1-5 days of symptoms with asymptomatic women the reference group. BP was measured at each visit in addition to demographic and clinic factors.

RESULTS

At baseline, 298 women reported frequent VMS, 794 less frequent VMS and 1747 no VMS. More frequent baseline VMS was associated with higher BP. Compared to no VMS, baseline VMS was associated with HTN (odds ratio [OR] 1.47, 95% confidence interval [CI]; 1.14-1.88 for infrequent VMS, and OR 1.40, (95% CI; 0.97-2.02 for frequent VMS). Risk for incident pre-HTN or HTN during follow-up was increased among women with frequent VMS (hazard ratio of 1.39, 95% CI; 1.09-1.79) after adjustment for multiple covariates.

CONCLUSION

Women with VMS may be more likely to develop HTN compared to women without VMS. Further research related to VMS including frequency of symptoms is warranted.

[Clinical practice guideline. Diagnosis and treatment of postmenopausal and perinemopausia]

Post-menopause is the period of life where a deep decline occurs in circulating estrogen levels, inducing the appearance of psycho and somatic symptoms. The classification to understand the chronology of reproductive aging in women (known as STRAW) determines the clinical and endocrine changes contemplating menstrual cycles, symptoms, measurements of FSH, LH, inhibin B, anti-Mullerian hormone , and follicular account. The diagnosis of menopause is established by the absence of menstruation for 12 months or more. The most frequent clinical manifestations of the climacteric syndrome transition to menopause are menstrual disorders, vasomotor symptoms (flushes and/or sweats) and genitourinary manifestations. The assessment of women in the peri- or postmenopause aims to develop: cervicovaginal cytology , lipid profile , serum glucose, basal Mammography at least a year before, pelvic ultrasound, urinalysis, serum TSH, Densitometry in patients older than 60 years if there is no recourse can be applied and FRAX. Drug therapy for the treatment of disorders of the transition to menopause or menopause is divided into: hormone therapy (HT) based estrogens and progestin hormone not being the most recommended the serotonin reuptake inhibitors and norepinephrine, clonidine, gabapentin or veralipride.

Evaluation of the presence and severity of menopausal symptoms among postmenopausal women screened for the metabolic syndrome

BACKGROUND

The prevalence of the metabolic syndrome (METS) increases after the menopause. Reports indicate that the METS and its components, especially obesity, enhance the intensity of menopausal symptoms.

OBJECTIVE

Assess the frequency and severity of menopausal symptoms in postmenopausal women. Factors related to the symptom severity were also analyzed including depressive and metabolic status.

METHODS

A total of 204 natural postmenopausal women (40-65 years) participating in a METS screening program were asked to fill out the Menopause Rating Scale (MRS), the Hospital Anxiety and Depression Scale (HADS), and a general socio-demographic questionnaire containing personal and partner data. Criteria of the American Heart Association were used to define the METS.

RESULTS

Median age of the whole sample was 56 years. A 52.9% presented the METS, with 37.3% presenting hyperglycemia, 51.5% hypertension, 58.3% abdominal obesity, 45.6% high triglyceride and 56.4% low HDL-C levels. Total and subscale MRS scores did not differ in accordance to the presence or not of the METS. The three top prevalent menopausal symptoms were muscle and joint problems (87.2%), physical and mental exhaustion (72%) and depressive mood (64.7%). A 19.6% of women presented total MRS scores above 16 defined as severe. Multivariate linear regression analysis determined that anxiety (higher HADS anxiety subscale scores) was significantly and positively correlated with all components of the MRS (Total and subscale scores). Higher total MRS scores correlated positively with abdominal perimeter and higher parity. Somatic scores correlated inversely with female education and positively with psychotropic drug use; and psychological MRS scores positively correlated depressed mood (higher HADS depressive subscale scores) and abdominal perimeter.

CONCLUSION

In this postmenopausal sample, severity of menopausal symptoms correlated to abdominal obesity, mood and other personal aspects.

[Comparison of the frequency and magnitude of the vasomotor symptoms in premenopausal and postmenopausal women from Mexico City]

BACKGROUND

Decreased ovarian function is associated with several symptoms, being the more frequent the vasomotor and these are associated to several factors.

OBJECTIVE

To describe the frequency and magnitude of vasomotor symptoms in premenopausal and postmenopausal women from Mexico City.

MATERIAL AND METHODS

A comparative, cross-sectional study was carried out from July 2011 to February 2012 in which somatometry was done and a questionnaire was applied to women beginning from 35 years age, evaluating their menopausal status, educational level, occupation, vasomotor symptoms (hot-flushes and sweats), intensity, frequency and the number of days per week with symptoms. Sample size was calculated considering a confidence interval of 99%, a power of 80%, with a frequency of symptoms presentation in premenopausal women of 55% and 85% in those postmenopausal, with a relationship of 1:1, considering 60 patients in each group.

STATISTICAL ANALYSIS

A comparison among the groups was done for continuous variables with Student t test for independent samples and for discontinuous variables with chi2, a p level < 0.05 was considered statistically significant.

RESULTS

Of the total population (144 women), 65 (45%) had vasomotor symptoms, 38% did physical exercise and 50% had some chronic illness. Of the 79 premenopausal women (Group 1) 49% was symptomatic and of the 65 postmenopausal women, 46% (Group II). Of the symptomatic ones in the Group I, 100% presented hot-flushes and 77% considered their symptoms severe; in Group II 85% had hot-flushes and the symptoms were considered severe by 63%.

CONCLUSION

The vasomotor symptoms were only associated to time since menopause.

Circadian rhythm of hot flashes and activity levels among prostate cancer patients on androgen deprivation therapy

OBJECTIVE

Altered circadian rhythms have been identified in untreated prostate cancer patients. Findings of restored rhythmicity following cancer treatment may have relevance for cancer control and symptom management. This study assessed and compared the cyclic patterns of hot flashes and activity levels in treated prostate cancer patients.

METHODS

Data were collected during two 24-h periods among 47 prostate patients undergoing androgen deprivation therapy (ADT). Hot flashes were detected objectively through sternal skin conductance and by patients via electronic event marking. Activity levels were recorded on a wrist actigraphy device.

RESULTS

The mean frequency of objectively measured and patient-reported hot flashes was 13.6 (SD = 14.3) and 12.6 (SD = 9.6), respectively. There were significant 24-h circadian rhythms of both hot flashes and activity levels. The peak of the rhythms occurred in early afternoon. There was no significant cross correlation between hot flashes and activity levels.

CONCLUSIONS

The acrophases of hot flashes and elevated activity levels in this study may represent a normalisation of circadian rhythms following ADT, pointing to the need for more research, including controlled, prospective chronobiologic studies. Future research may have important implications for the survival of prostate cancer patients and the identification of new and safe hot flash treatments.

Frequency of symptoms, determinants of severe symptoms, validity of and cut-off score for Menopause Rating Scale (MRS) as a screening tool: a cross-sectional survey among midlife Nepalese women

BACKGROUND

Majority of Nepalese women live in remote rural areas, where health services are not easily accessible. We determined the validity of Menopause Rating Scale (MRS) as a screening tool for identification of women with severe menopausal symptoms and cut-off MRS score for referral.

METHODS

A cross-sectional survey was carried out between February and August, 2008. Trained health workers administered MRS and a questionnaire to 729 women (40 to 65 years) attending health screening camps in Kaski district of Western Development Region of Nepal. Information about demographics, menopausal status, and use of hormone replacement therapy (HRT), chronic disease, self-perceived general health and reproductive history was also collected. Menopausal status was classified according to the Staging of Reproductive Ageing Workshop (STRAW). We calculated rates of menopausal symptoms, sensitivity, and specificity and likelihood ratios of MRS scores for referral to a gynaecologist. We also carried out multivariate analyses to identify the predictors for referral to a gynaecologist for severe symptoms.

RESULTS

A total 729 women were interviewed. Mean age at menopause was 49.9 years (SD 5.6). Most frequently reported symptoms were, sleeping problems (574, 78.7%), physical and mental exhaustion (73.5%), hot flushes (508, 69.7%), joint and muscular discomfort (500, 68.6%) and dryness of vagina (449, 61.6%). Postmenopausal women (247, 33.9%) and perimenopausal (215, 29.5%) women together experienced significantly higher prevalence of all symptoms than the premenopausal (267, 36.6%) women. MRS score of ≥16 had highest ratio for (sensitivity + specificity)/2. Women who reported urogenital symptoms [OR 5.29, 95% CI 2.59, 10.78], and self perceived general health as poor [OR 1.29, 95% CI 1.11, 1.53] were more likely to be referred to a gynaecologist for severe menopausal symptoms. While women reporting somatic [OR 0.72, 95% CI 0.63, 0.82] and psychological [OR 0.86, 95% CI 0.74, 0.99] symptoms were less likely to be referred.

CONCLUSION

MRS may be used as a screening tool at a cut-off score of ≥16 with least misclassification rate. However, its utility may be limited by woman's general health status and occurrence of urogenital symptoms.

Nonhormonal management of hot flashes for women on risk reduction therapy

Hot flashes are very common in women in menopause and can have a detrimental effect on quality of life. Women on risk reduction therapy are particularly prone because treatments, such as tamoxifen, raloxifene, or oophorectomy, have the potential to exacerbate these symptoms. Hormonal treatments, despite the fact that they represent the most effective therapies, are not used for the treatment of hot flashes in these women because of concerns that they may increase the risk for breast cancer. As a result, several nonhormonal therapies have been tested in randomized placebo-controlled trials and shown to be effective, such as paroxetine, venlafaxine, desvenlafaxine, fluoxetine, citalopram, gabapentin, and pregabalin. In addition, several nonpharmacologic therapies have been tested with various successes. An additional consideration is how some of those drugs, especially fluoxetine and paroxetine, interact with the metabolism of tamoxifen. This article discusses these issues, and provides some recommendations regarding use of nonhormonal therapies for treating hot flashes in women on risk reduction therapy, with an emphasis on pharmacogenomic considerations.

[Partner relationships in menopausal period]

OBJECTIVES

Evaluation of partner relationships in menopausal period.

MATERIAL AND METHODS

A questionnaire study was performed in a group of 67 women (age: 45-55 years) and their partners. The inclusion criteria were: presence of climacteric symptoms, stable partnership, consent to research. 40 women and their spouses were included into the final study group. The investigative tool was based on 3 scales: Marriage Bond Scale (SWM); Scale of Attractiveness (SKAT); GREEN Scale evaluating intensification of menopausal symptoms and a set of additional questions concerning socio-demographical data, marital sexuality and substitute hormonal therapy.

RESULTS

Mean age of respondents was 52 years. Most of the women demonstrated an amenorrhea (90%). Climacteric symptoms such as: hot flush, stress, depressive moods (87.5% each), musculoarticular pain (80%) occurred in various degree. 97.5% of women did not use a substitute hormonal treatment. The mean result of SWM for women and their partners scored 237 which is 79% of the total value. A correlation between exacerbation of menopausal signs and SWM score was not found. The co-attractiveness ratio counted on the basis of SKAT scale scored 30 points on average, which constitutes 74% of the maximum. Approximately 58% of the men accepted symptoms related to menopause in their partners; they tolerated changes appearing in the climacteric period, however; 100% of men did not talk about menopausal problems with their partners and did not support them in this difficult time.

CONCLUSIONS

Men find their partners attractive in the perimenopausal period, accepting their partners and problems related to menopause. Most of the male respondents understand changes occurring in their partners, however, they do not help them to deal with them.

Comparison of objective and patient-reported hot flash measures in men with prostate cancer

Hot flashes are one of the bothersome symptoms frequently experienced after endocrine treatments for breast and prostate cancers. Many studies have evaluated interventions for hot flashes, but results are obscured by methodologic limitations. We compared the performance of three techniques to measure hot flashes over 48 hours among 47 patients with prostate cancer undergoing androgen deprivation therapy to determine the feasibility and accuracy of each measure. Sternal skin conductance, electronic event marking, and twice daily diaries identified 478, 410, and 285 hot flashes, respectively. Diaries produced the lowest hourly hot flash rate (M = 0.17), which was significantly different from the rates of the objective profile (M = 0.28) and event marks (M = 0.23).The sensitivity and positive predictive value of the three measures demonstrated that the diaries underperformed, but these values did not exceed moderate levels for any measure (% = 28-59). Study results suggest the combined use of sternal skin conductance and event marking for the measurement of hot flash frequency in pathophysiologic studies and clinical trials with prostate cancer patients. Conversely, the use of retrospective diaries may be adequate for clinical practice to determine clinically significant changes in salient events.

Predictors of sleep quality in women in the menopausal transition

STUDY OBJECTIVES

To determine associations between menopausal status, reproductive hormone levels, menopausal symptoms, and poor sleep quality.

DESIGN

The present study examines subjective sleep quality over an 8-year period in participants in an ongoing longitudinal study of ovarian aging in a randomly identified cohort of African American and Caucasian women.

PARTICIPANTS

The Penn Ovarian Aging Study, a population-based cohort of 436 women from Philadelphia County who were 35 to 47 years of age and had regular menstrual cycles at enrollment.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

The primary outcome measure was the Sleep Quality factor score, derived from the St. Mary's Hospital Sleep Questionnaire, which was adapted for this population and collected at each assessment period over the 8-year follow-up. Associations between menopausal status, reproductive hormone levels, menopausal symptoms, sleep quality, age, and race were examined in multivariable linear mixed regression models for repeated measures. Menopausal status was not significantly associated with sleep quality (P = 0.12). In the adjusted model, independent predictors of sleep quality were hot flashes (P < 0.0001), Center for Epidemiological Studies Depression Scale scores (P < 0.0001) and levels of the reproductive hormone inhibin B (P = 0.05).

CONCLUSIONS

Sleep quality was predicted by hormone levels and symptoms that occur in the menopausal transition but did not worsen with advancing menopausal status alone. Lower inhibin B levels, hot flashes, and symptoms of depression were all strong and independent predictors of difficulty sleeping. Race was not a significant contributor to sleep quality. Together, the findings demonstrate that women who experience other perimenopausal symptoms are likely to experience sleep problems during the menopausal transition.

Symptoms during the menopausal transition and early postmenopause and their relation to endocrine levels over time: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

To determine whether hot flashes, depressed mood, sleep, cognitive and sexual symptoms correlate with urinary follicle-stimulating hormone (FSH), estrone (E(1)G), and testosterone (T) and with each other during the menopausal transition and early postmenopause (PM).

METHODS

Forty-one women who transitioned from middle or late transition stage to PM rated symptoms and provided monthly urine specimens as part of a longitudinal study of the menopausal transition.

RESULTS

Correlations between endocrine levels and symptom severity ratings over time revealed that hot flash severity was significantly and positively related to FSH and negatively to E1 G. Vaginal dryness was positively correlated with FSH and negatively correlated with T. Decreased sexual desire was correlated negatively with E(1)G levels. Forgetfulness was positively correlated with FSH; difficulty concentrating was negatively correlated with T. Severity of sleep symptoms and depressed mood were not correlated with E(1)G, FSH, or T. Correlations among the symptoms revealed that severity of hot flashes was associated with sleep disruption and forgetfulness. Depressed mood was correlated with sleep disruption, difficulty concentrating, and decreased sexual desire but not with hot flashes or vaginal dryness. Awakening during the night was correlated with decreased sexual desire and vaginal dryness, as well as hot flashes. Forgetfulness was associated with hot flashes and difficulty concentrating, whereas difficulty concentrating was associated with depressed mood and early awakening.

CONCLUSIONS

Symptoms many women experience during the menopausal transition and early PM are related to different endocrine levels (FSH, E(1)G, and T).

Sleep, Fatigue, and Depressive Symptoms in Breast Cancer Survivors and Matched Healthy Women Experiencing Hot Flashes

PURPOSES/OBJECTIVES

To compare sleep quality and disturbance, fatigue, and depressive symptoms between breast cancer survivors and healthy women experiencing hot flashes and to examine relationships among sleep and remaining variables (fatigue, depressive symptoms, and frequency of hot flashes).

DESIGN

Cross-sectional, descriptive, comparative pilot study.

SETTING

University-based outpatient setting.

SAMPLE

15 breast cancer survivors and 15 healthy women matched on age, race, and menopausal status. All women had untreated hot flashes (no hormone replacement therapy or other hot flash treatments).

METHODS

Questionnaires (sleep quality and disturbance, fatigue, and depression); two ambulatory, 24-hour sternal skin conductance monitoring sessions (hot flash frequency); and medical records review.

MAIN RESEARCH VARIABLES

Sleep quality and disturbance, fatigue, depressive symptoms, and objective hot flash frequency.

FINDINGS

The majority of participants evidenced poor sleep quality and high sleep disturbance (73% of breast cancer survivors and 67% of healthy women above a cutoff score of 5). Sleep duration was significantly shorter for breast cancer survivors in contrast to healthy women. Nighttime flashes were experienced by 67% of breast cancer survivors and 37% of healthy women. No group differences were found in fatigue, depressive symptoms, or objective hot flash frequency. Global sleep scores were significantly positively correlated with fatigue and depression but not with hot flash frequency.

CONCLUSIONS

Findings suggest that sleep disturbance is common in menopausal breast cancer survivors and healthy women, is not necessarily related to hot flashes, and may stem from a multifactorial etiology.

IMPLICATIONS FOR NURSING

Menopausal breast cancer survivors who present with any one of these symptoms should be screened for all symptoms both during and after treatment.

Exploring the prevalence of menopause symptoms in midlife women in methadone maintenance treatment

Menopause is a natural process that occurs in women's lives as part of normal aging. Many women go through the menopausal transition with few or no symptoms, while some have significant or even disabling symptoms. The purpose of this paper is to describe the menopausal symptom experience of 135 urban methadone-maintained midlife women between the ages of 40 and 55 years. A cross-sectional survey comprising sample characteristic questions and a 14-item menopause symptom checklist was administered. Ninety-six percent reported one or more symptoms with a mean of 6.2 symptoms. Symptom reporting was found to be relatively high, with more than half of the sample reporting hot flashes, night sweats, sleep disturbances, joint pains, and fatigue in the two weeks preceding the survey. However, the psychological symptoms (irritability and depression) were the two most common symptoms in this sample. This study documents a relatively heavy burden of symptoms in an aging cohort of methadone-maintained women. The physical and psychological impact of aging and, in particular, the experience of menopause in these women is rarely studied and poorly understood. This gap in critical knowledge is further complicated by the remarkable similarity of many symptoms associated with menopause and opiate withdrawal. Aging, drug-related health problems, and poor access to health care further complicate the picture and underscore the importance of better integration of health care with social work intervention.

SUMEVA, a new system of climacteric symptom evaluation, and its correlation with FSH and estradiol levels

OBJECTIVE

To evaluate a new climacteric symptom scale (SUMEVA) and to assess its correlation with follicle stimulating hormone (FSH) and estradiol (E2) levels.

METHODS

115 healthy perimenopausal women who were not receiving, nor had received, hormone therapy were studied. They were asked to complete 3 questionnaires concerning climacteric symptoms: (1) Kupperman's index (KI), (2) Green scale (GS), and (3) SUMEVA, which is the sum of symptom evaluations done in an analog visual scale. FSH and E2 determinations were done by chemoluminiscence.

STATISTICAL ANALYSIS

The comparison among the groups was done by Student's t test. Pearson correlation analysis was done between FSH and E2 levels and KI, the GS, and SUMEVA.

RESULTS

There were 60 women with FSH < or = 30 mIU/mL (group I) and 55 with FSH > 30 mIU/mL (group II). The KI average in the whole group was 13.2 +/- 8.1, the GS 20.6 +/- 13.1, and the SUMEVA 65.6 +/- 44.9. The three scales had a significant correlation between them.

CONCLUSIONS

No correlation of KI, GS, or SUMEVA was found with FSH and E2 levels, but the SUMEVA was as effective as the other previously validated, scales for climacteric symptom evaluation.

Menopausal Vasomotor Symptoms (MVS) Survey for Assessment of Hot Flashes

OBJECTIVES

During the menopause, 65%-80% of women experience hot flashes. Hot flashes can also occur after hysterectomy and may be experienced during cancer therapy. A very limited assessment of hot flashes is provided by currently available menopausal instruments. This study was performed to evaluate a new Menopausal Vasomotor Symptoms (MVS) survey as an instrument for a comprehensive and subjective assessment of hot flashes.

METHODS

The MVS survey was designed to assess multiple dimensions of hot flashes and to be simple and easy to administer. Hot flashes and associated conditions were addressed with 39 closed-ended questions. Sixty-one qualified women, 40-58 years old, from the Dallas, Fort Worth Metroplex area were enrolled. Women experiencing hot flashes took the survey at baseline and then 14 days, 2 months, and 6 months later. Factor analysis was performed. Face and content validity, internal consistency, test-retest reliability, and sensitivity to changes were evaluated.

RESULTS

Fifty-two women (85.2%) completed all study sessions. The MVS survey was found to have good face and content validity and good internal consistency (rhoKR = 0.87). Spearman rank-order correlation coefficients at the 14-day retest varied from 0.58 to 1.00. As a result of these analyses, the MVS survey was further refined.

CONCLUSIONS

The MVS survey was found to be comprehensive, simple, valid, reliable, sensitive, and a convenient instrument for subjective assessment of various characteristics of hot flashes. The MVS survey may serve as a valuable clinical and research tool for measurement of hot flashes.

State of the science: hot flashes and cancer. Part 1: definition, scope, impact, physiology, and measurement

PURPOSE/OBJECTIVES

To critically evaluate and synthesize multidisciplinary research related to hot flashes in the context of cancer. Topics include the definition, scope, and impact of hot flashes; physiologic mechanisms; and measurement issues.

DATA SOURCES

Published, peer-reviewed articles and textbooks; editorials; unpublished data; and computerized databases.

DATA SYNTHESIS

Hot flashes can affect a diverse group of men and women diagnosed with or at high risk for certain cancers with a resulting negative impact on quality of life. Although the exact physiologic mechanisms underlying hot flashes remain unclear, a complex interplay of thermoregulatory, gluconeuroendocrine, genetic, and behavioral factors appears to be involved. Measurement of hot flashes should be considered carefully because they can be operationalized objectively and subjectively.

CONCLUSIONS

The large and diverse evidence base and current national attention on measurement of hot flashes highlight the importance of the symptom to healthcare professionals, including oncology nurses.

IMPLICATIONS FOR NURSING

Careful attention to assessment and measurement of hot flashes in patients with cancer is needed.

Accuracy of subjective hot flush reports compared with continuous sternal skin conductance monitoring

OBJECTIVE

To compare 2 subjective and 1 objective method for assessing hot flush frequency: prospective paper hot flush diaries, prospective electronic event markers, and the Biolog ambulatory sternal skin conductance monitor.

METHODS

Fifty-five breast cancer survivors provided two 24-hour periods of data, 1 week apart, at baseline before being randomized for an intervention study. Women completed a prospective paper hot flush diary and pressed an event marker to subjectively record each hot flush they experienced while wearing a sternal skin conductance monitor.

RESULTS

Sensitivity was uniformly low (< 50%) for both subjective methods at each week. The estimated probability that a woman would record a true monitor-verified hot flush subjectively by diary or event marker was between 36% and 50% of the time if she was awake and between 22% and 42% of the time if she was asleep. Underreporting of diary hot flushes consequently resulted in more than 50% missing severity and bother ratings. Specificity was high (96-98%) for both the diary and event marker, for both weeks, and for both waking and sleeping times. The positive predictive value was low (34-52%), and negative predictive value was high (94-97%). This indicates that, rather than overreporting hot flushes when they did not exist, women tended to underreport hot flushes when they did exist.

CONCLUSION

Use of prospective paper hot flush diaries and electronic event markers may seriously underestimate hot flush frequency and result in missed intensity and bother ratings.

Validation of the Women's Health Initiative Insomnia Rating Scale in a multicenter controlled clinical trial

OBJECTIVE

The objective of this study was to evaluate the construct validity of the five-item Women's Health Initiative Insomnia Rating Scale (WHIIRS) by comparing women taking hormone therapy (HT) versus those taking a placebo and by comparing women known to differ in vasomotor symptoms.

METHODS

The WHIIRS was included in two phase III randomized trials intended to evaluate the efficacy of a combination estradiol plus and norethindrone acetate transdermal delivery system in reducing vasomotor symptoms. In all, 850 healthy postmenopausal women participated in these studies. Both trials were double-blind, one was placebo-controlled and the other was positive-controlled. The former trial admitted women with > or =8 hot flashes/day and lasted 12 weeks with data collected on the WHIIRS at baseline, 4, 8, and 12 weeks. The other trial had no entry criteria pertaining to hot flashes and lasted 52 weeks with WHIIRS data collected at baseline, 12, 24, and 52 weeks.

RESULTS

The WHIIRS was sensitive to the effect of HT on sleep disturbance over time. The WHIIRS also detected differences in self-reported sleep disturbance between women with mild vasomotor symptoms compared with those with moderate to severe symptoms. As expected, the study using a positive control revealed that sleep improved over time (p <.0001). Also as predicted, the study using a placebo control found that sleep disturbance in the treatment groups improved at a faster rate than in the control groups (p = .035).

CONCLUSION

The construct validity of the WHIIRS was supported because it was successfully used to detect self-reported sleep disturbance differences in women taking HT versus those taking a placebo as well as in groups known to differ in severity of their vasomotor symptoms.

Emotional antecedents of hot flashes during daily life

OBJECTIVE

Hot flashes are among the most frequently reported menopausal symptoms. However, little is known about factors associated with their occurrence. Moreover, despite the wide use of self-report hot flash measures, little is known about their concordance with physiological flashes. This study evaluated emotional and behavioral antecedents of subjectively and objectively measured hot flashes during daily life. It also examined individual differences predicting concordance between objective and subjective hot flashes.

METHODS

Forty-two perimenopausal or postmenopausal women (mean age = 50.5 +/- 4.8 years) reporting daily hot flashes completed 2 days of ambulatory sternal skin conductance monitoring, behavioral diaries 3 times an hour, and psychometric questionnaires. Hot flashes meeting objective physiological criteria and subjectively reported flashes not meeting physiological criteria were assessed. Likelihood of hot flashes following emotions and activities were examined in a case-crossover analysis.

RESULTS

Relative to nonflash control times, objective hot flashes were more likely after increased happiness, relaxation, and feelings of control, and less likely after increased frustration, sadness, and stress. Conversely, subjective hot flashes not meeting physiological criteria were more likely after increased frustration and decreased feelings of control. Questionnaires revealed increased negative mood and negative attitudes were associated with fewer objective flashes and higher false-positive reporting rates.

CONCLUSION

Increased positive and decreased negative emotions were associated with objective hot flashes, whereas increased negative and decreased positive emotions were associated with subjective flashes not meeting physiological criteria. The anecdotal association between negative emotions and hot flashes may be the result of self-reported flashes lacking physiological corroboration.

Perimenopause: More Than Hot Flushes and Night Sweats for Some Australian Women

OBJECTIVE

To identify the most common perimenopausal symptoms experienced by a group of Australian women and explore the extent to which those symptoms were distressing.

DESIGN

A quantitative survey.

SETTING

All women's health centers listed with the New South Wales Women's Information and Referral Service.

PARTICIPANTS

A convenience sample of 200 healthy women, aged 45 to 55 years, drawn from a statewide population of women residing in Australia.

MAIN OUTCOME MEASURE

The Women's Health Assessment Scale.

RESULTS

Most frequently occurring perimenopausal symptoms included forgetfulness, lack of energy, irritability, and weight gain. The most distressing perimenopausal symptoms included weight gain, heavy bleeding, poor concentration, leaking of urine, and feeling as though life were not worth living. Current use of hormone replacement therapy contributed to the prediction of both symptom occurrence and symptom distress.

CONCLUSION

Perimenopause is marked by more than hot flushes and night sweats; cognitive and affective changes are other distressing symptoms. The relationships between hormone replacement therapy use and both symptom occurrence and symptom distress warrant further investigation. In addition, practitioners should address concerns related to urinary incontinence, weight gain, cognitive and affective dysfunction, and general health status.

A longitudinal evaluation of the relationship between reproductive status and mood in perimenopausal women

OBJECTIVE

Mood and reproductive function were prospectively evaluated in asymptomatic premenopausal women to determine whether the onset of depression was temporally linked to the perimenopause.

METHOD

Twenty-nine asymptomatic, regularly cycling women were monitored longitudinally for an average of 5 years until at least 6 months of amenorrhea occurred. Outcome measures included mood ratings and menstrual diaries completed daily, the Structured Clinical Interview for DSM-IV, and plasma levels of follicle-stimulating hormone obtained at 3-6-month intervals. The number of episodes of depression and their timing relative to the final menstrual period were determined. Differences in outcome measures between women who did and did not become depressed during the perimenopause were determined by Student's t test, chi-square tests, and Fisher's exact test.

RESULTS

The authors observed 11 episodes of new-onset depression in nine of the 29 women. In the 24 months surrounding the last menstrual period nine episodes of depression were observed. Six of the nine women who became depressed during the study had no prior depressive episodes. For the 24 months surrounding the final menses, the risk for onset of depression was 14 times as high as for a 31-year premenopausal period of time. Women who developed depression during the perimenopause were not distinguished from those who remained asymptomatic on the basis of symptom profile, duration of the perimenopause, endocrine measures, or past historical variables.

CONCLUSIONS

These preliminary data suggest that events related to the late perimenopause may be associated with an increased susceptibility to develop depression in some women.

The association between nocturnal hot flashes and sleep in breast cancer survivors

This study examined the relationship between objectively measured nocturnal hot flashes and objectively measured sleep in breast cancer survivors with insomnia. Twenty-four women who had completed treatment for non-metastatic breast cancer participated. All were enrolled in a study of cognitive-behavioral treatment for chronic insomnia. Nocturnal hot flashes and sleep were measured by skin conductance and polysomnography, respectively. The 10-minute periods around hot flashes were found to have significantly more wake time, and more stage changes to lighter sleep, than other 10-minute periods during the night. Nights with hot flashes had a significantly higher percentage of wake time, a lower percentage of Stage 2 sleep, and a longer REM latency compared to nights without hot flashes. Overall, hot flashes were found to be associated with less efficient, more disrupted sleep. Nocturnal hot flashes, or their underlying mechanisms, should be considered as potential contributors to sleep disruption in women with breast cancer who report poor sleep.

Measuring hot flashes: summary of a National Institutes of Health workshop

The etiology and mechanism of hot flashes remain incompletely understood. Future studies of hormonal and neurologic systems may provide promising leads to improve our understanding of the basic phenomenon and perhaps also shed light on the placebo effect. However, this is likely a complex undertaking. Critical to this effort is the ability to reliably identify when a hot flash has occurred. The leading objective measure in use today--sternal skin conductance monitoring--has some limitations in ambulatory settings. However, a more severe limitation is the inability of sternal skin conductance to provide any information on duration, intensity, and interference with activities. Ultimately, researchers desire a convenient and cost-effective sensor for monitoring hot flashes without cumbersome electrodes that might become compromised if a subject experiences extensive sweating or takes a shower and one that can capture data continuously for relatively long periods of observation. However, researchers also need well-characterized methods for collecting self-reported data. If the primary concern is helping women with hot flashes find relief, then subjective measures collected through diaries or interviews cannot be dismissed. Given the importance of this information, it would make sense to undertake methodologic research to ensure that the best possible systems are used to collect valid and reliable information. The factors that we want to measure with respect to hot flashes are likely to change over time as more is learned about the underlying phenomenon. This will probably be an evolutionary process, one involving decisions about what biological factors will be most useful for the task at hand, what technologies might be available or easily adaptable, which measures should be bundled together to maximize the precision of data collected with the available technology, and the analysis of the data to generate new hypotheses and perhaps the need for new measurement tools. Investigators face several challenges when considering the design of studies of hot flashes. Substantial placebo effects and small sample sizes have produced studies with equivocal findings. The placebo effect, while remarkable in its dimensions in some studies of hot flash interventions, is not understood. Distinguishing placebo effects from the natural dissipation of symptoms over time would be extremely helpful. Similarly, the ability to induce a placebo effect to reduce the discomfort and annoyance associated with hot flashes might be helpful. The use of neuroimaging technology offers potential for greater understanding of the placebo effect. The group concluded that better measures of hot flashes require improved knowledge in several areas: The physical processes underlying hot flashes, which will identify additional factors to measure and the factors that influence the perception and reporting of hot flashes. Improved sternal skin conductance systems, with additional tools to be developed when other factors of hot flashes are identified. The performance characteristics of questionnaires and diaries to collect self-reported data on hot flash frequency. Improved and validated instruments for collecting data on intensity and interference with daily activities. The mechanism(s) of action of placebo, which may also help distinguish natural attrition of symptoms from placebo effect. Animal models to elucidate triggers and mechanisms of hot flashes and to screen potential treatments. Investigators interested in studying hot flashes face complex issues. The incomplete understanding of the basic physiology underlying hot flashes clearly calls for further work in this area. Some mechanistic studies cannot be conducted with human subjects; thus, animal models are needed. Animal models could be particularly helpful for understanding the neurobiology of hot flashes and perhaps placebo effects. Bringing scientists together from different fields would appear to be a promising approach to moving this area forward. Scientific advances are being made increasingly at the interfaces of traditional disciplines, and approaches to science are becoming more integrative. Finding appropriate collaborators from other disciplines is not necessarily easy, and meeting a collaborator from another discipline is only the first step in building a multidisciplinary research team. Effective teams begin with compelling reasons for their existence, but further incentives must be developed to ensure full realization of their potential. The success of team science depends on individuals who are comfortable with boundary-crossing activities. Working as part of a team that is seeking solutions to complex problems requires a willingness to work in an interdisciplinary environment, to collaborate with different types of organizations, and to recognize the importance of a variety of roles in the project. It is likely that a multidisciplinary approach to hot flash research would be helpful given the number of physiologic, clinical, and behavioral factors involved. For example, psychologists and sociologists could contribute to identifying factors that may influence the placebo effect, such as pill color; developing and validating questionnaire items and diary formats; ascertaining the effect of mode of data collection on the quality of the resulting data; and determining the best ways to provide information to subjects. However, if they were part of a multidisciplinary team that included basic scientists, clinicians, and bioengineers, different questions might be asked, and better tools might be developed to collect both subjective and objective data on hot flashes. The increasing emphasis on collaborative science is also embraced at the NIH level. Since May 2002, the NIH has been engaged in a series of activities collectively known as the "NIH Roadmap," whose goal, in keeping with the NIH mission of uncovering new knowledge about the prevention, detection, diagnosis, and treatment of disease and disability, is to accelerate both the pace of discovery in these key areas and the translation of therapies from bench to bedside. The timing of this workshop to assess measures of hot flashes appears auspicious for several reasons. First, the issue of refining and validating self-reported measures of symptoms through the use of biomarkers and multidisciplinary research teams is consonant with an NIH Roadmap initiative. Second, the new National Institute for Biomedical Imaging and Bioengineering at the NIH offers impetus for linking biomedical, social, and behavioral scientists with bioengineers to assess and improve existing technology or develop new technologies to collect data on physiological markers specific to hot flashes. Third, people are already purchasing and using CAM modalities or are resuming hormone therapy for relief of hot flashes, and they and their clinicians are eager for and deserve more information on the safety and efficacy of these remedies.

Transition from estrogen-progestin to raloxifene in postmenopausal women: effect on vasomotor symptoms

OBJECTIVE

To compare vasomotor symptoms after transition from estrogen-progestin therapy to raloxifene 60 mg/d with and without a placebo washout.

METHODS

Postmenopausal women currently taking continuous combined estrogen-progestin therapy (conjugated equine estrogen, 0.625 mg/medroxyprogesterone acetate, 2.5 or 5 mg) daily for 5 or more months were enrolled. Women were randomized to 1 of 4 blinded regimens: 1) 12 weeks estrogen-progestin; 2) 12 weeks placebo; 3) 4 weeks placebo, then 8 weeks raloxifene; or 4) 12 weeks raloxifene. For the final 36 weeks, all subjects received raloxifene. Vasomotor symptoms were assessed by patient diaries.

RESULTS

A total of 266 women (mean age 57.5) were enrolled. Mean hot flush frequency at baseline was approximately 1 per week in the entire population, with 16% of women reporting hot flushes. Mean frequency and severity of hot flushes during the first 12 weeks of the study were statistically greater in the 3 groups transitioned off estrogen-progestin (range of hot flushes per week: 4 weeks, 11-12; 8 weeks, 18-24; 12 weeks, 13-16), as compared with those continuing estrogen-progestin, with no difference between these 3 groups (P> or =.1). Approximately 50-70% of these women reported hot flushes, generally rated as mild to moderate by participants, after estrogen-progestin discontinuation.

CONCLUSION

A large proportion of women discontinuing estrogen-progestin experience hot flushes. Raloxifene does not appear to increase the frequency or severity of vasomotor symptoms in women discontinuing estrogen-progestin more than that observed with placebo treatment after estrogen-progestin discontinuation. Transition from estrogen-progestin to raloxifene with no washout period therefore may be acceptable.

LEVEL OF EVIDENCE

I

Relief of Hot Flushes With New Plant-Derived 10-Component Synthetic Conjugated Estrogens

OBJECTIVE

A study was conducted to evaluate the safety and efficacy of 3 different doses of synthetic conjugated estrogens B, a new plant-derived 10-component conjugated estrogens product, for the treatment of menopausal vasomotor symptoms.

METHODS

This was a randomized, double-blind, placebo-controlled trial. Highly symptomatic menopausal women (N = 281) received 12 weeks of a once-daily oral treatment with 0.3 mg, 0.625 mg, or 1.25 mg of 10-component synthetic conjugated estrogen or placebo. Patients recorded the daily frequency and severity of hot flushes. Statistical analyses compared results at weeks 4, 8, and 12 with baseline values.

RESULTS

Statistically significant reductions (P <.05) in the frequency and severity of vasomotor symptoms were observed for all 3 dosage strengths of 10-component synthetic conjugated estrogen compared with placebo. The most commonly reported adverse events in all treatment groups were headaches. No difference in the incidence of treatment-related adverse events was seen between placebo and 10-component synthetic conjugated estrogen groups.

CONCLUSION

The 0.3-mg, 0.625-mg and 1.25-mg dose strengths of 10-component synthetic conjugated estrogen significantly reduced the frequency and severity of vasomotor symptoms compared with placebo, and were well tolerated during this 12-week study.

LEVEL OF EVIDENCE

I

Gabapentin's effects on hot flashes in postmenopausal women: a randomized controlled trial

OBJECTIVE

To evaluate whether treatment with the anticonvulsant gabapentin may be effective in reducing hot flash frequency and severity.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted in 59 postmenopausal women with seven or more hot flashes per day examining the effects of gabapentin 900 mg per day on hot flash frequency after 12 weeks of treatment. Subsequently, study patients were enrolled in a 5-week, open-label treatment phase, during which patients could increase the dose of gabapentin to 2,700 mg per day, if needed.

RESULTS

After 12 weeks of double-blind treatment, intention-to-treat analysis showed that gabapentin 900 mg per day was associated with a 45% reduction in hot flash frequency and a 54% reduction in hot flash composite score (frequency and severity combined into one score) from baseline, compared with 29% (P =.02) and 31% (P =.01) reductions, respectively, for placebo. Four patients (13%) in the gabapentin group and one (3%) in the placebo group withdrew from the double-blind study because of adverse events. Fifteen patients (50.0%) in the gabapentin group reported at least one adverse event, compared with eight patients (27.6%) in the placebo group. Higher, open-label gabapentin dosing was associated with 54% and 67% reductions in hot flash frequency and composite score from baseline, respectively.

CONCLUSION

Gabapentin is effective in reducing hot flash frequency and severity in postmenopausal women.

The immediate effect of natural plant extract, Angelica sinensis and Matricaria chamomilla (Climex) for the treatment of hot flushes during menopause. A preliminary report

OBJECTIVE

To assess the efficiency of a medicinal herb extract preparation (Climex) for the treatment of menopausal symptoms.

METHOD

In this placebo-controlled experiment on 55 postmenopausal women who complained of hot flushes and refused hormonal therapy. The women were randomly divided into two groups, one to receive Climex (5 chewable tablets daily between meals) and the other group to receive a placebo; both groups would take the tablets for 12 weeks. The women were asked to complete a daily structured (Kupperman) questionnaire assessing the frequency and intensity of menopausal symptoms, starting one week prior to treatment to the completion of the study. All women underwent hormone profile measurements and transvaginal ultrasonography evaluation before and after treatment.

RESULTS

There was a significant difference between the study group and the control group in the decrease in number and intensity of hot flushes from baseline to completion of treatment (90-96% vs 15-25%, p < 0.001). In the study group, a response was already noted during the first month of treatment (68% +/- 2% reduction of hot flushes during the day and 74% +/- 4% during the night). There was also a marked alleviation of sleep disturbances and fatigue.

CONCLUSIONS

Treatment with Climex seems to be effective for menopausal symptoms without apparent major adverse effects. This hormone-free preparation may be used as an important modality for menopausal women with contraindications for hormone replacement therapy.

Menopausal symptoms in older women and the effects of treatment with hormone therapy

OBJECTIVE

In some women, hot flashes and other symptoms attributed to menopause persist for many years after the cessation of menses. The frequency and severity of such symptoms and response to hormone therapy in older women have not been well documented.

METHODS

We used data from the Heart and Estrogen/Progestin Replacement Study, a blinded, clinical trial among 2763 women with documented coronary disease and a uterus who were randomized to receive either conjugated estrogens 0.625 mg plus medroxyprogesterone acetate 2.5 mg in one tablet or placebo. Participants were queried at baseline and annually regarding menopausal symptoms. Breast symptoms were self-reported, and uterine bleeding was recorded on a daily diary.

RESULTS

Symptoms associated with menopause were relatively common among Heart and Estrogen/Progestin Replacement Study participants, whose average age was 67 years and who averaged 18 years since menopause. At baseline, 16% of women reported frequent hot flashes, 26% vaginal dryness, 10% genital irritation, 55% trouble sleeping, and 53% early awakening. Women assigned to hormone therapy reported less frequent hot flashes, vaginal dryness, and trouble sleeping compared with women assigned to placebo, but more frequent vaginal discharge, genital irritation, uterine bleeding, and breast symptoms. The reporting of breast symptoms among women in the hormone group decreased from 40% at 1 year to 13% by the 4th year. Uterine bleeding was reported by 31% and spotting by an additional 33% of women in the hormone group during the 1st year of treatment; by the 4th year, these proportions had fallen to 11% and 20%, respectively.

CONCLUSION

Symptoms typically attributed to menopause are common in elderly women. Postmenopausal hormone therapy reduces hot flashes, trouble sleeping, and vaginal dryness, but at standard doses in elderly women is associated with vaginal discharge, genital irritation, uterine bleeding, and breast symptoms.

Pilot evaluation of gabapentin for treating hot flashes

OBJECTIVE

To obtain pilot prospective data regarding the efficacy and tolerability of gabapentin for alleviating hot flashes.

PATIENTS AND METHODS

This prospective single-arm clinical trial was conducted between July 26, 2001, and November 30, 2001. Patients underwent a baseline week and then 4 weeks of gabapentin treatment, with increasing doses during the first 3 weeks, from 300 to 600 to 900 mg/d. Data were obtained primarily from patient-completed questionnaires.

RESULTS

Data from 20 evaluable women (of 24 entered in the trial) were available. Four patients discontinued use of gabapentin for perceived drug-related untoward symptoms, primarily related to light-headedness and dizziness. The 16 patients who completed this clinical trial had a mean reduction in hot flash frequency, in the fourth treatment week compared to the baseline week, of 66%. Their corresponding hot flash score (frequency times average severity) reduction was 70%. Additionally, patients who completed the 4 treatment weeks had a strong tendency to report an improvement in several other symptoms.

CONCLUSION

Although a double-blind placebo-controlled clinical trial should be conducted to better elucidate the efficacy and toxicity of gabapentin in patients with hot flashes, the available data suggest that gabapentin is a reasonable treatment to consider in patients with hot flashes if they do not wish to use hormonal therapy.

Pathophysiology and treatment of hot flashes

Hot flashes affect about three fourths of postmenopausal women and are one of the most common health problems in this demographic group. Dysfunction of central thermoregulatory centers caused by changes in estrogen levels at the time of menopause has long been postulated to be the cause of hot flashes. Treatment should begin with a careful patient history, with specific attention to the frequency and severity of hot flashes and their effect on the individual's function. For mild symptoms that do not interfere with sleep or daily function, behavioral changes in conjunction with vitamin E (800 IU/d) use is a reasonable initial approach. For more severe symptoms, the next step is to determine whether there is a contraindication or a personal reservation to estrogen replacement therapy. For women who are able and willing to use estrogen, it will successfully relieve symptoms by about 80% to 90%. In patients with a history of breast or uterine cancer, treatment with the progestational agent megesterol acetate appears to be a safe alternative that also decreases hot flashes by approximately 80%. For women unwilling or unable to use hormone therapy, one of the newer antidepressant agents can be prescribed. Venlafaxine decreases hot flashes by about 60%. Gabapentin is another drug that appears promising as therapy for women unable or unwilling to use estrogen, and the results of ongoing trials to determine its efficacy are eagerly awaited. The use of clonidine, methyldopa, and belladonna should be discouraged because of their modest efficacy and adverse effects.

Measurement of hot flashes by sternal skin conductance and subjective hot flash report in Puebla, Mexico

OBJECTIVE

To measure hot flashes by sternal skin conductance in an urban Mexican population and to determine variables associated with hot flash reporting and measurement.

DESIGN

From June 1999 to August 2000, 67 perimenopausal women aged 40 to 65 years participated in interviews, anthropometric measures, and a 2-h recording of sternal skin conductance. Changes in sweating were used to demonstrate the presence/absence of a hot flash. During the test, women were asked to report if they experienced a hot flash.

RESULTS

During the study period, 10 women reported and demonstrated every hot flash, 24 women never reported or demonstrated a hot flash, 7 demonstrated hot flashes but did not report any of them, 7 reported hot flashes but did not demonstrate any of them, and 19 showed a mixture of responses. Women who demonstrated hot flashes by sternal skin conductance were measured in a warmer room, had more years of education, consumed more eggs as a child, recalled a heavier weight at age 18, and had a lower body mass index at interview compared with women who did not demonstrate hot flashes by sternal skin conductance. Women who subjectively reported hot flashes were measured in a warmer room, were more likely to be postmenopausal, reported more frequent consumption of coffee, and spent fewer months breast-feeding their last child compared with women who did not report the experience of hot flashes during the testing period.

CONCLUSION

Room temperature explained part of the variation between women who did and did not demonstrate hot flashes via sternal skin conductance, between women who did and did not report the experience of hot flashes, and between women who did and did not demonstrate concordance in objective and subjective measures. In addition to room temperature, coffee intake, months spent breast-feeding the last child, and recalled weight at age 18 were important variables predicting hot flash experience.

Intramuscular depot medroxyprogesterone versus oral megestrol for the control of postmenopausal hot flashes in breast cancer patients: a randomized study

BACKGROUND

Hot flashes are frequent in postmenopausal breast cancer patients, especially when treated with tamoxifen. Estrogen replacement therapy is the most effective treatment for hot flashes, but its use is controversial in breast cancer survivors. Progestins may offer a good alternative for the control of hot flashes in this setting; in particular, oral megestrol acetate has been proven effective in a randomized, placebo-controlled clinical trial. With the aim of further improving these results, we have designed a randomized study comparing oral megestrol acetate with depot intramuscular (i.m.) medroxyprogesterone acetate (MPA) for the control of hot flashes in postmenopausal patients with a history of breast cancer.

PATIENTS AND METHODS

Seventy-one postmenopausal patients were randomized to receive an i.m. injection of depot MPA 500 mg on days 1, 14 and 28, or oral megestrol acetate 40 mg daily for 6 weeks. Patients recorded daily the number and severity of their hot flashes; response was defined as a > or =50% decrease in the number and severity of hot flashes.

RESULTS

At week 6, hot flashes were reduced by 86% on average in the whole group of patients, without significant differences between the two progestins. Response was obtained by 75 and 67% of patients receiving MPA or megestrol, respectively (P = 0.5). Responders were followed to assess maintenance of response (without further treatment), which was significantly better with i.m. MPA: in this group, 89% of responders still showed a benefit at week 24, compared with 45% in the megestrol group (P = 0.03).

CONCLUSIONS

Our study shows that a short cycle of i.m. depot MPA injections provides significant and long-lasting relief from postmenopausal hot flashes in patients with a history of breast cancer, offering an alternative to estrogen replacement therapy or prolonged administration of oral megestrol.

Physiology of hot flashes

Hot flashes are the most common symptom of the climacteric, although prevalence estimates are lower in some rural and non-Western areas. The symptoms are characteristic of a heat-dissipation response and consist of sweating on the face, neck, and chest, as well as peripheral vasodilation. Although hot flashes clearly accompany the estrogen withdrawal at menopause, estrogen alone is not responsible since levels do not differ between symptomatic and asymptomatic women. Until recently it was thought that hot flashes were triggered by a sudden, downward resetting of the hypothalamic setpoint, since there was no evidence of increased core body temperature. Evidence obtained using a rapidly responding ingested telemetry pill indicates that the thermoneutral zone, within which sweating, peripheral vasodilation, and shivering do not occur, is virtually nonexistent in symptomatic women but normal (about 0.4 degrees C) in asymptomatic women. The results suggest that small temperature elevations preceding hot flashes acting within a reduced thermoneutral zone constitute the triggering mechanism. Central sympathetic activation is also elevated in symptomatic women which, in animal studies, reduces the thermoneutral zone. Clonidine reduces central sympathetic activation, widens the thermoneutral zone, and ameliorates hot flashes. Estrogen virtually eliminates hot flashes but its mechanism of action is not known.

Tamoxifen treatment and gynecologic side effects: a review

OBJECTIVE

To review the literature on tamoxifen side effects on the female genital tract and psychosexual function in premenopausal and postmenopausal women.

DATA SOURCES

We used the English-language literature in MEDLINE and reference lists from selected articles. Search terms included: "tamoxifen and estrogen receptor," "transcription activation," "premenopause," "postmenopause," "vaginal epithelium," "uterus," "endometrial hyperplasia," "polyps," "endometrial cancer," "sonography," "sonohysterography," "hysteroscopy," "myometrium," "myoma," "sarcoma," "endometriosis," "ovarian cysts," "hot flushes," "concentration problems," "sleep disturbance," "vaginal dryness," "sexual function," "libido," "dyspareunia," and "quality of life." No study-type restrictions were imposed.

METHODS OF STUDY SELECTION

With respect to clinical studies we included case cohort studies, observational studies; if no trials were available on a subject, case reports published in peer-reviewed journals were selected. For the discussion on endometrial surveillance of tamoxifen users, letters and editorials published in peer-reviewed journals also were used. Subjects of interest were mechanism of action of tamoxifen, tamoxifen and the vaginal epithelium, endometrium, mesenchymal tumors of the uterus, ovaries, sexual function, and vasomotor instability.

TABULATION, INTEGRATION, AND RESULTS

Eligible studies were analyzed to determine their usefulness in this review. Data from trials that evaluated tamoxifen side effects on specific genital tissues were combined, with special interest in differentiation of side effects in premenopausal and postmenopausal women. Weighted estimates of severity and extent of side effects were usually not possible because of lack of randomized trials. Only the risk of endometrial cancer in relation to tamoxifen treatment could be estimated.

CONCLUSION

The gynecologic side effects of tamoxifen are diverse and reflect the complexity of its mechanism of action, with agonistic and antagonistic effects on various tissues, depending on the ambient estradiol concentration and hence menopausal status of the patient. The most frequently reported side effect was hot flushes, and the most worrisome gynecologic side effect was a two- to three-fold increased risk of endometrial cancer in postmenopausal women. Despite its side effects, the benefits of tamoxifen in controlling breast cancer or prevention of its relapse are still without debate.